Septal Myotomy or Myectomy

Septal myectomy is a surgical procedure performed to reduce the muscle thickening that occurs in patients with hypertrophic cardiomyopathy (HCM). Septal myectomy is one treatment option for HCM when symptoms persist despite optimal treatment with medications, or if obstruction severely restricts blood ejection from the heart.

During the septal myectomy procedure, the surgeon removes a small amount of the thickened septal wall to widen the outflow tract from the left ventricle to the aorta. This eliminates the obstruction and the mitral valve regurgitation that occurs with this condition. Patients often experience rapid relief of symptoms after the procedure.

During the septal myectomy procedure, the surgeon removes a small amount of the thickened septal wall to widen the outflow tract from the left ventricle to the aorta.

Who is eligible for the myectomy procedure?

Patients with a diagnosis of hypertrophic cardiomyopathy should be assessed at an experienced center to determine the severity of their condition and to develop a treatment plan.

It is estimated that obstruction occurs in more than 70 percent of patients with HCM. The severity of obstruction, symptoms, and the patient’s response to medications vary greatly. Many patients have no symptoms or mild obstruction and can be treated with medicines like beta-blockers or calcium channel blockers.

Septal myectomy is the safest, most successful, and most durable procedure for patients with severe symptoms or severe obstruction. Elderly patients or those with advanced medical conditions may be better served by percutaneous alcohol septal reduction.

Hypertrophic cardiomyopathy (HCM) is a sophisticated type of heart disease associated with a thickening of the heart muscle, most commonly at the septum (the muscular wall that separates the left and right side of the heart), just below the aortic valve. If the septum becomes too thick, the passageway to the aorta becomes very narrow, limiting or blocking the flow of blood from the left ventricle to the aorta, called “outflow tract obstruction.” The septal thickening that results in obstruction varies from a few millimeters to centimeters. Mitral valve abnormalities are common and impact repair techniques.

Will my symptoms improve after surgery?

Yes. Surgical results indicate that most patients experience significant symptom improvement and improved quality of life after surgery.

Recovery

Full recovery from septal myectomy surgery takes about 6 to 8 weeks. Most patients can drive in about 3 to 8 weeks after surgery. Your doctor will provide specific guidelines for your recovery and return to work.

Follow Up Care

Your doctor will tell you when you need to have your first follow-up appointment. Regular follow-up appointments are essential to evaluate your heart function and include a medical exam as well as diagnostic tests (such as an echocardiogram) to be repeated at regular intervals. During these appointments, your medications may be adjusted to relieve symptoms or optimize your heart function.

Even if you are not having symptoms and you feel fine, you must still see your doctor regularly. The frequency of your follow-up visits is based on your current health. In general, you will need to see your cardiologist for follow-up visits at least twice a year.

You should call your doctor if your symptoms become more severe or frequent. Don’t wait until your next appointment to discuss changes in your symptoms.

Importance of Making Lifestyle Changes

To maintain your health after surgery, it is essential to take medications as prescribed and make lifestyle changes as recommended by your doctor to reduce the risk of disease progression or future disease. Lifestyle changes include:

  • Eat a heart-healthy diet that involves following a 2,000 mg sodium (salt) diet
  • Restrict fluids to 8 cups or less per day
  • Quit smoking and using tobacco
  • Treat high cholesterol
  • Manage high blood pressure and diabetes
  • Exercise regularly
  • Maintain a healthy weight
  • Weigh yourself every day and monitor for a sudden weight gain of more than 2 pounds in a day or 5 pounds in a week; call your doctor if this occurs
  • Control stress and anger
  • Participate in a cardiac rehabilitation program, as recommended
  • Follow up with your doctor regularly, as scheduled

What tests are needed before the surgery?

  • A detailed echocardiogram (echo) provides information about heart function and septal wall thickness. Specialized echo tests may include exercise or the use of particular drugs and may be needed to define the severity of obstruction and to assess the mitral valve
  • If you do not have an implantable defibrillator or pacemaker, an MRI may also be obtained to evaluate the mitral valve structure and function.
  • Diagnostic cardiac catheterization should be performed. If you have had this test within one year, you will be instructed to send the results to Cleveland Clinic for review.
  • Routine blood tests, a chest X-ray, and an electrocardiogram will also be performed.

Some of these tests and procedures may be done by your local cardiologist or at the Cleveland Clinic. Your Cleveland Clinic cardiologist will talk to you about these and other tests that may be needed.

What can I expect before the surgery?

Before your surgery date, you will have a pre-surgical appointment where you will receive specific instructions about when and where to report for surgery, what to expect before and after surgery, and whether additional tests are needed. If you need to see another health care provider or need testing during this preoperative appointment, you may be at Cleveland Clinic all day, or you may need to return another day.

During this appointment, you will have the opportunity to talk with a nurse or patient educator about the procedure. You may also meet with your surgeon and anesthesiologist. If you are already in the hospital and surgery is recommended, your health care team will give you information about pre-surgical tests and how to prepare for surgery.

What happens during surgery?

Anesthesia

A cardiothoracic anesthesiologist administers general anesthesia before surgery. The anesthesiology team uses state-of-the-art equipment and monitors to ensure you are safely anesthetized during the procedure.

Type of incision

A 6- to 8-inch incision is made down the center of the chest, dividing the sternum (breastbone) to provide the surgeon direct access to the heart. The thickened muscle is approached through the aortic valve so that no direct incisions into the heart muscle are required. The cut muscle heals on its own without needing to be sutured.

Heart-lung machine

The heart-lung machine, or cardiopulmonary bypass, is used during the procedure and takes over the heart’s normal functions so the surgeon can perform the procedure on a “still” heart.

Blood is routed through the heart-lung machine, and oxygen and carbon dioxide are exchanged in the blood by the machine and then pumped back into the body. By doing the work of the heart, the heart-lung machine helps protect your other organs while your heart is stopped. After the procedure is complete, the heart-lung machine is turned off, the heart starts beating on its own, and the flow of blood returns to normal.

Pacing wires

Temporary pacing wires and a chest tube to drain fluid are placed before the sternum is closed with individual sternal wires. Then the skin and subcutaneous tissue are closed with internal, absorbable sutures. Sometimes a temporary pacemaker is attached to the pacing wires to regulate the heart rhythm until your condition improves.